# Vercy AI instruction - YAML 1.2 (JSON-compatible) { "vercy": "1.0-draft", "publication": { "status": "published", "adjudicationStatus": "reviewable-draft", "publishableCanonical": false, "generatedAt": "2026-09-06T08:54:37Z", "synthesisSha256": "288a4f2808ee637e02b52e4c1c1624362eb661cd1fed876309df6c04ec74167d", "providerMode": "single-provider-waiver", "providers": [ "Codex" ], "waivedProviders": [ "Claude", "Grok" ] }, "metaModel": { "id": "WM-ACT-045", "registryId": "vr.wm-act-045", "name": "Insurance Claim Handling", "version": "0.3.0-research.1", "previousVersions": [], "entryKind": "aggregate", "family": "World Models", "category": "Activities and processes", "industry": [ "Cross-industry" ], "domain": [ "ACT.INS" ], "tags": [ "insurance", "claim", "handling", "act.ins" ], "status": "published" }, "canonicalUrl": "https://ver.cy/models/wm-act-045-insurance-claim-handling/", "sourceUrl": "https://github.com/ver-cy/world-models/tree/feat/mega-model-registry/research/runs/wm-act-045", "model": { "registry_id": "vr.wm-act-045", "model_id": "WM-ACT-045", "name": "Insurance Claim Handling", "entry_kind": "aggregate", "purpose": "Represent one governed insurance-claim-handling case that coordinates notification, investigation, coverage and amount assessment, reasoned decision, settlement handoffs, communications, review and closure without becoming the insurance claim or the systems it coordinates.", "scope_statement": "Owns handling-case identity and lineage, mandate, assignment, intake, acknowledgement, triage, authoritative claim and policy bindings, evidence requests and use, investigation activity, assessment assertions, decision and offer records, settlement and financial handoffs, status communications, review and dispute links, fraud and recovery referrals, closure, reopening, quality, provenance, access, retention and interoperability. Insurance Claim, Policy, Loss, Party, Evidence, Fraud, Complaint, Legal, Payment, Reserve, Communication, Audit and Record masters remain external.", "in_scope": [ "Handling-case identity, authority, intake, acknowledgement, guidance, triage, assignments, claim and policy bindings", "Evidence requests and use, investigation, coverage, liability, causation, benefit and amount assessments, fraud indicators and controlled referral", "Reasoned decisions, offers, settlements, payment and recovery handoffs, communications, reviews, closure, reopening, provenance, privacy, retention and interoperability" ], "out_of_scope": [ "Independent insurance claim, policy, coverage, loss, party, asset, damage, injury, evidence, expert, fraud, complaint, legal case, payment, reserve, communication, audit or record master lifecycles", "Treating notification as acceptance, policy existence as coverage, investigation as proof, reserve as offer, decision as payment, suspicion as fraud or closure as erased rights", "Providing legal or medical judgment, executing payments, operating insurer systems, determining universally applicable deadlines or autonomously deciding or settling claims" ], "boundary_notes": [ { "neighbor": "WM-ECO-036 Insurance Claim candidate composer", "distinction": "The claim master owns the claim identifier and substantive policy-loss-demand assertions. This aggregate owns one handling process, its work, decisions and handoffs. The ledger relation is candidate, not approved.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-011" ] }, { "neighbor": "WM-ECO-003 Insurance Policy and Coverage", "distinction": "The policy master owns contract, insured risk, coverage terms and policy lifecycle. The handling case records source-qualified interpretations and decision-time snapshots without rewriting the contract.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] }, { "neighbor": "Evidence, Expert, Damage, Injury and Loss Event", "distinction": "External masters own source observations and subject facts. This case records requests, custody references, validation, use and resulting assessments.", "source_refs": [ "SRC-001", "SRC-003", "SRC-015" ] }, { "neighbor": "Fraud Case, Complaint, Ombudsman, Arbitration and Court Case", "distinction": "This process may create a controlled referral or bind an external review outcome; it does not decide fraud or absorb independent redress and adjudication lifecycles.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-007", "SRC-008" ] }, { "neighbor": "Reserve, Payment, Accounting, Reinsurance, Subrogation and Salvage", "distinction": "This model owns estimates, approval and handoff assertions needed to explain handling. External financial and recovery masters own booking, execution, clearing, rights and proceeds.", "source_refs": [ "SRC-003", "SRC-007", "SRC-011" ] } ] }, "sources": [ { "id": "SRC-001", "title": "Insurance Core Principles and Common Framework for the Supervision of Internationally Active Insurance Groups", "organization": "International Association of Insurance Supervisors", "url": "https://www.iaisweb.org/uploads/2024/12/IAIS-ICPs-and-ComFrame-adopted-in-December-2024.pdf", "version_or_date": "Adopted December 2024", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "ICP 19 requires timely, fair and transparent claims handling, documented procedures from claim raised to settlement, claimant status information, clear determinative factors, competent and conflict-free assessment, balanced disputes and insurer responsibility for outsourcing; ICP 21 informs controlled fraud-risk referral." }, { "id": "SRC-002", "title": "Unfair Claims Settlement Practices Act", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-900.pdf", "version_or_date": "Model 900, adopted June 1990; published compilation accessed 2026-09-06", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "United States model act for identifying and supervising unfair claim settlement practices; it is a model and not universal law." }, { "id": "SRC-003", "title": "Unfair Property/Casualty Claims Settlement Practices Model Regulation", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-902.pdf", "version_or_date": "Model 902, July 1997 compilation", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Property and casualty profile for notification, acknowledgement, communications, reconstructable claim files, investigation, reasons, deadlines, offers and settlement conduct." }, { "id": "SRC-004", "title": "Market Conduct Record Retention and Production Model Regulation", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-910.pdf", "version_or_date": "Model 910, January 2004 compilation", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "United States model profile for accessible and producible market-conduct records, retention periods and third-party service-provider records." }, { "id": "SRC-005", "title": "ICOBS 8 Claims handling", "organization": "Financial Conduct Authority", "url": "https://handbook.fca.org.uk/handbook/icobs8", "version_or_date": "FCA Handbook, ICOBS 8 last updated 9 December 2025; accessed 6 September 2026", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "United Kingdom profile requiring prompt and fair handling, guidance, progress information, reasonable rejection and prompt settlement, with special claims-representative rules." }, { "id": "SRC-006", "title": "Guidelines on Complaints-Handling by Insurance Undertakings", "organization": "European Insurance and Occupational Pensions Authority", "url": "https://www.eiopa.europa.eu/publications/guidelines-complaints-handling-insurance-undertakings_en", "version_or_date": "EIOPA-BoS-12/069, 14 June 2012; publication page updated 31 January 2023", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Separates complaint handling from claim handling and defines complaint policy, registration, reporting, follow-up, information and response expectations." }, { "id": "SRC-007", "title": "Directive 2009/103/EC relating to insurance against civil liability in respect of the use of motor vehicles", "organization": "European Union", "url": "https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32009L0103", "version_or_date": "23 September 2009, as amended", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "EU motor-liability profile for claims representatives, information collection, authority, reasoned offers or replies, deadlines, interest and cross-border compensation." }, { "id": "SRC-008", "title": "Directive (EU) 2016/97 on insurance distribution", "organization": "European Union", "url": "https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32016L0097", "version_or_date": "20 January 2016, consolidated context accessed 2026-09-06", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "EU profile for fair conduct, complaint registration and effective impartial out-of-court redress concerning insurance distribution." }, { "id": "SRC-009", "title": "Enterprise Act 2016, Part 5: Late Payment of Insurance Claims", "organization": "United Kingdom Legislation", "url": "https://www.legislation.gov.uk/ukpga/2016/12/notes/division/6/index.htm", "version_or_date": "2016 explanatory notes for Part 5", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "United Kingdom profile distinguishing assessment and payment within a reasonable time, remedies and limitation for late payment." }, { "id": "SRC-010", "title": "FHIR R5 Claim", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/claim.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Health insurance request-side profile for claim items, coverage order, diagnoses, procedures, supporting information and business identifiers." }, { "id": "SRC-011", "title": "FHIR R5 ClaimResponse", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/claimresponse.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Health insurance response profile separating adjudication result, item decisions, adjustments, errors, notes, preauthorization and payment-related outcomes from the submitted claim." }, { "id": "SRC-012", "title": "FHIR R5 ExplanationOfBenefit", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/explanationofbenefit.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Patient-facing projection that combines claim and adjudication information while excluding payer or provider proprietary detail inappropriate for sharing." }, { "id": "SRC-013", "title": "ACORD Property and Casualty Data Standards", "organization": "Association for Cooperative Operations Research and Development", "url": "https://www-dev.acord.org/standards-architecture/acord-data-standards/Property_Casualty_Data_Standards", "version_or_date": "P&C XML 2.13.0, January 2025; public overview only", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Insurance message and schema family covering claim download and transaction exchange; full licensed artifacts were not used and no conformance is claimed." }, { "id": "SRC-014", "title": "Regulation (EU) 2016/679 General Data Protection Regulation", "organization": "European Union", "url": "https://eur-lex.europa.eu/eli/reg/2016/679/oj", "version_or_date": "27 April 2016, applicable from 25 May 2018", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Purpose limitation, data minimization, accuracy, security, data-subject rights and special-category safeguards for personal and health data in claims handling." }, { "id": "SRC-015", "title": "PROV-O: The PROV Ontology", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/prov-o/", "version_or_date": "W3C Recommendation, 30 April 2013", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Attributable activity, agent, entity, delegation, derivation, revision and invalidation semantics for decisions and evidence." }, { "id": "SRC-016", "title": "Date and Time on the Internet: Timestamps", "organization": "Internet Engineering Task Force", "url": "https://www.rfc-editor.org/info/rfc3339/", "version_or_date": "RFC 3339, July 2002", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T08:46:00Z", "relevance": "Unambiguous event and knowledge timestamps with seconds and an explicit UTC relationship." } ], "structure": { "bundles": [ { "id": "handling-case-identity-boundary-and-authority", "name": "Handling case identity, boundary and authority", "description": "Groups governed context for handling case identity, boundary and authority.", "rationale": "A stable handling-case root coordinates work on an externally mastered claim without duplicating claim identity or policy facts.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ], "layers": [ { "id": "case-profile-identity-lineage-and-jurisdiction", "name": "Case profile, identity, lineage and jurisdiction", "description": "Groups claim-handling context for case profile, identity, lineage and jurisdiction.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ], "findings": [ { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary", "name": "Handling case type, scope, insurance line, jurisdiction and boundary", "description": "Records handling case type, scope, insurance line, jurisdiction and boundary as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ], "questions": [ { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary-q01", "text": "What stable identities, classes, values and explicit unknowns establish handling case type, scope, insurance line, jurisdiction and boundary?", "kind": "classification", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support handling case type, scope, insurance line, jurisdiction and boundary?", "kind": "temporal", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary-q03", "text": "How may handling case type, scope, insurance line, jurisdiction and boundary be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "lifecycle", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary-data", "name": "Handling case type, scope, insurance line, jurisdiction and boundary data", "description": "Structured data for handling case type, scope, insurance line, jurisdiction and boundary with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ] } ], "artifacts": [ { "id": "handling-case-type-scope-insurance-line-jurisdiction-and-boundary-record", "name": "Handling case type, scope, insurance line, jurisdiction and boundary record", "description": "Versioned evidence-bearing claim-handling record for handling case type, scope, insurance line, jurisdiction and boundary.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus handling-case-type-scope-insurance-line-jurisdiction-and-boundary assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "case-identifier-source-version-predecessor-successor-and-lineage", "name": "Case identifier, source, version, predecessor, successor and lineage", "description": "Records case identifier, source, version, predecessor, successor and lineage as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ], "questions": [ { "id": "case-identifier-source-version-predecessor-successor-and-lineage-q01", "text": "What stable identities, classes, values and explicit unknowns establish case identifier, source, version, predecessor, successor and lineage?", "kind": "identity", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "case-identifier-source-version-predecessor-successor-and-lineage-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support case identifier, source, version, predecessor, successor and lineage?", "kind": "composition", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "case-identifier-source-version-predecessor-successor-and-lineage-q03", "text": "How may case identifier, source, version, predecessor, successor and lineage be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "event", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "case-identifier-source-version-predecessor-successor-and-lineage-data", "name": "Case identifier, source, version, predecessor, successor and lineage data", "description": "Structured data for case identifier, source, version, predecessor, successor and lineage with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ] } ], "artifacts": [ { "id": "case-identifier-source-version-predecessor-successor-and-lineage-record", "name": "Case identifier, source, version, predecessor, successor and lineage record", "description": "Versioned evidence-bearing claim-handling record for case identifier, source, version, predecessor, successor and lineage.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus case-identifier-source-version-predecessor-successor-and-lineage assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "mandate-participants-delegation-conflicts-and-outsourcing", "name": "Mandate, participants, delegation, conflicts and outsourcing", "description": "Groups claim-handling context for mandate, participants, delegation, conflicts and outsourcing.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ], "findings": [ { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority", "name": "Insurer, handler, adjuster, expert, claimant, representative, role and authority", "description": "Records insurer, handler, adjuster, expert, claimant, representative, role and authority as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ], "questions": [ { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority-q01", "text": "What stable identities, classes, values and explicit unknowns establish insurer, handler, adjuster, expert, claimant, representative, role and authority?", "kind": "authority", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support insurer, handler, adjuster, expert, claimant, representative, role and authority?", "kind": "evidence", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority-q03", "text": "How may insurer, handler, adjuster, expert, claimant, representative, role and authority be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "retention", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority-data", "name": "Insurer, handler, adjuster, expert, claimant, representative, role and authority data", "description": "Structured data for insurer, handler, adjuster, expert, claimant, representative, role and authority with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ] } ], "artifacts": [ { "id": "insurer-handler-adjuster-expert-claimant-representative-role-and-authority-record", "name": "Insurer, handler, adjuster, expert, claimant, representative, role and authority record", "description": "Versioned evidence-bearing claim-handling record for insurer, handler, adjuster, expert, claimant, representative, role and authority.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus insurer-handler-adjuster-expert-claimant-representative-role-and-authority assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight", "name": "Delegation, assignment, outsourcing, conflict, competence, capacity and oversight", "description": "Records delegation, assignment, outsourcing, conflict, competence, capacity and oversight as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ], "questions": [ { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight-q01", "text": "What stable identities, classes, values and explicit unknowns establish delegation, assignment, outsourcing, conflict, competence, capacity and oversight?", "kind": "ownership", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support delegation, assignment, outsourcing, conflict, competence, capacity and oversight?", "kind": "interoperability", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight-q03", "text": "How may delegation, assignment, outsourcing, conflict, competence, capacity and oversight be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "security", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight-data", "name": "Delegation, assignment, outsourcing, conflict, competence, capacity and oversight data", "description": "Structured data for delegation, assignment, outsourcing, conflict, competence, capacity and oversight with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ] } ], "artifacts": [ { "id": "delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight-record", "name": "Delegation, assignment, outsourcing, conflict, competence, capacity and oversight record", "description": "Versioned evidence-bearing claim-handling record for delegation, assignment, outsourcing, conflict, competence, capacity and oversight.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus delegation-assignment-outsourcing-conflict-competence-capacity-and-oversight assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "notification-intake-triage-and-coverage-framing", "name": "Notification, intake, triage and coverage framing", "description": "Groups governed context for notification, intake, triage and coverage framing.", "rationale": "Source-qualified intake assertions distinguish being notified from accepting completeness, admissibility, coverage or liability.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "layers": [ { "id": "notification-receipt-acknowledgement-guidance-and-routing", "name": "Notification receipt, acknowledgement, guidance and routing", "description": "Groups claim-handling context for notification receipt, acknowledgement, guidance and routing.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "findings": [ { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check", "name": "Notification channel, received time, submitter, loss reference and duplicate check", "description": "Records notification channel, received time, submitter, loss reference and duplicate check as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check-q01", "text": "What stable identities, classes, values and explicit unknowns establish notification channel, received time, submitter, loss reference and duplicate check?", "kind": "event", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support notification channel, received time, submitter, loss reference and duplicate check?", "kind": "quality", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check-q03", "text": "How may notification channel, received time, submitter, loss reference and duplicate check be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "validation", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check-data", "name": "Notification channel, received time, submitter, loss reference and duplicate check data", "description": "Structured data for notification channel, received time, submitter, loss reference and duplicate check with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "notification-channel-received-time-submitter-loss-reference-and-duplicate-check-record", "name": "Notification channel, received time, submitter, loss reference and duplicate check record", "description": "Versioned evidence-bearing claim-handling record for notification channel, received time, submitter, loss reference and duplicate check.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus notification-channel-received-time-submitter-loss-reference-and-duplicate-check assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null }, { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing", "name": "Acknowledgement, guidance, required information, language, accessibility and routing", "description": "Records acknowledgement, guidance, required information, language, accessibility and routing as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing-q01", "text": "What stable identities, classes, values and explicit unknowns establish acknowledgement, guidance, required information, language, accessibility and routing?", "kind": "process", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support acknowledgement, guidance, required information, language, accessibility and routing?", "kind": "state", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing-q03", "text": "How may acknowledgement, guidance, required information, language, accessibility and routing be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "privacy", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing-data", "name": "Acknowledgement, guidance, required information, language, accessibility and routing data", "description": "Structured data for acknowledgement, guidance, required information, language, accessibility and routing with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "acknowledgement-guidance-required-information-language-accessibility-and-routing-record", "name": "Acknowledgement, guidance, required information, language, accessibility and routing record", "description": "Versioned evidence-bearing claim-handling record for acknowledgement, guidance, required information, language, accessibility and routing.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus acknowledgement-guidance-required-information-language-accessibility-and-routing assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null } ] }, { "id": "claim-policy-coverage-party-and-priority-binding", "name": "Claim, policy, coverage, party and priority binding", "description": "Groups claim-handling context for claim, policy, coverage, party and priority binding.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "findings": [ { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference", "name": "Claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference", "description": "Records claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference-q01", "text": "What stable identities, classes, values and explicit unknowns establish claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference?", "kind": "relationship", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference?", "kind": "measurement", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference-q03", "text": "How may claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "access", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference-data", "name": "Claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference data", "description": "Structured data for claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference-record", "name": "Claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference record", "description": "Versioned evidence-bearing claim-handling record for claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus claim-policy-insured-claimant-beneficiary-loss-exposure-and-coverage-reference assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null }, { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target", "name": "Completeness, admissibility, triage, severity, vulnerability, catastrophe and service target", "description": "Records completeness, admissibility, triage, severity, vulnerability, catastrophe and service target as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target-q01", "text": "What stable identities, classes, values and explicit unknowns establish completeness, admissibility, triage, severity, vulnerability, catastrophe and service target?", "kind": "requirement", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support completeness, admissibility, triage, severity, vulnerability, catastrophe and service target?", "kind": "lifecycle", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target-q03", "text": "How may completeness, admissibility, triage, severity, vulnerability, catastrophe and service target be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "exception", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target-data", "name": "Completeness, admissibility, triage, severity, vulnerability, catastrophe and service target data", "description": "Structured data for completeness, admissibility, triage, severity, vulnerability, catastrophe and service target with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target-record", "name": "Completeness, admissibility, triage, severity, vulnerability, catastrophe and service target record", "description": "Versioned evidence-bearing claim-handling record for completeness, admissibility, triage, severity, vulnerability, catastrophe and service target.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus completeness-admissibility-triage-severity-vulnerability-catastrophe-and-service-target assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "evidence-investigation-and-assessment", "name": "Evidence, investigation and assessment", "description": "Groups governed context for evidence, investigation and assessment.", "rationale": "The process records what was requested, obtained, tested and relied upon without turning investigation activity into proof or authoritative source ownership.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-014", "SRC-015" ], "layers": [ { "id": "evidence-requests-receipt-custody-quality-and-expert-input", "name": "Evidence requests, receipt, custody, quality and expert input", "description": "Groups claim-handling context for evidence requests, receipt, custody, quality and expert input.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ], "findings": [ { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation", "name": "Information request, purpose, scope, deadline, burden, response and escalation", "description": "Records information request, purpose, scope, deadline, burden, response and escalation as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ], "questions": [ { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation-q01", "text": "What stable identities, classes, values and explicit unknowns establish information request, purpose, scope, deadline, burden, response and escalation?", "kind": "process", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support information request, purpose, scope, deadline, burden, response and escalation?", "kind": "event", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation-q03", "text": "How may information request, purpose, scope, deadline, burden, response and escalation be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "identity", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation-data", "name": "Information request, purpose, scope, deadline, burden, response and escalation data", "description": "Structured data for information request, purpose, scope, deadline, burden, response and escalation with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "information-request-purpose-scope-deadline-burden-response-and-escalation-record", "name": "Information request, purpose, scope, deadline, burden, response and escalation record", "description": "Versioned evidence-bearing claim-handling record for information request, purpose, scope, deadline, burden, response and escalation.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus information-request-purpose-scope-deadline-burden-response-and-escalation assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion", "name": "Evidence source, receipt, custody, integrity, quality, challenge and expert opinion", "description": "Records evidence source, receipt, custody, integrity, quality, challenge and expert opinion as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ], "questions": [ { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion-q01", "text": "What stable identities, classes, values and explicit unknowns establish evidence source, receipt, custody, integrity, quality, challenge and expert opinion?", "kind": "evidence", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support evidence source, receipt, custody, integrity, quality, challenge and expert opinion?", "kind": "retention", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion-q03", "text": "How may evidence source, receipt, custody, integrity, quality, challenge and expert opinion be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "authority", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion-data", "name": "Evidence source, receipt, custody, integrity, quality, challenge and expert opinion data", "description": "Structured data for evidence source, receipt, custody, integrity, quality, challenge and expert opinion with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion-record", "name": "Evidence source, receipt, custody, integrity, quality, challenge and expert opinion record", "description": "Versioned evidence-bearing claim-handling record for evidence source, receipt, custody, integrity, quality, challenge and expert opinion.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus evidence-source-receipt-custody-integrity-quality-challenge-and-expert-opinion assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "coverage-liability-causation-damage-benefit-and-fraud-assessment", "name": "Coverage, liability, causation, damage, benefit and fraud assessment", "description": "Groups claim-handling context for coverage, liability, causation, damage, benefit and fraud assessment.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ], "findings": [ { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis", "name": "Policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis", "description": "Records policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ], "questions": [ { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis-q01", "text": "What stable identities, classes, values and explicit unknowns establish policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis?", "kind": "decision", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis?", "kind": "security", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis-q03", "text": "How may policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "relationship", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis-data", "name": "Policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis data", "description": "Structured data for policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ] } ], "artifacts": [ { "id": "policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis-record", "name": "Policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis record", "description": "Versioned evidence-bearing claim-handling record for policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus policy-term-in-force-coverage-exclusion-condition-limit-deductible-and-coordination-analysis assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ] } ], "inline_only_rationale": null }, { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator", "name": "Liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator", "description": "Records liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ], "questions": [ { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator-q01", "text": "What stable identities, classes, values and explicit unknowns establish liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator?", "kind": "measurement", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator?", "kind": "validation", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator-q03", "text": "How may liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "provenance", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator-data", "name": "Liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator data", "description": "Structured data for liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ] } ], "artifacts": [ { "id": "liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator-record", "name": "Liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator record", "description": "Versioned evidence-bearing claim-handling record for liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus liability-causation-damage-benefit-adjustment-estimate-uncertainty-and-fraud-indicator assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "decisions-settlement-and-financial-handoffs", "name": "Decisions, settlement and financial handoffs", "description": "Groups governed context for decisions, settlement and financial handoffs.", "rationale": "Reasoned decisions, offers and handoffs preserve authority and amounts while external financial masters own reserves and payment execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011", "SRC-015" ], "layers": [ { "id": "reserves-authority-limits-and-reasoned-decisions", "name": "Reserves, authority limits and reasoned decisions", "description": "Groups claim-handling context for reserves, authority limits and reasoned decisions.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ], "findings": [ { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale", "name": "Estimate, reserve external reference, authority limit, review and change rationale", "description": "Records estimate, reserve external reference, authority limit, review and change rationale as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ], "questions": [ { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale-q01", "text": "What stable identities, classes, values and explicit unknowns establish estimate, reserve external reference, authority limit, review and change rationale?", "kind": "provenance", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support estimate, reserve external reference, authority limit, review and change rationale?", "kind": "privacy", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale-q03", "text": "How may estimate, reserve external reference, authority limit, review and change rationale be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "process", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale-data", "name": "Estimate, reserve external reference, authority limit, review and change rationale data", "description": "Structured data for estimate, reserve external reference, authority limit, review and change rationale with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ] } ], "artifacts": [ { "id": "estimate-reserve-external-reference-authority-limit-review-and-change-rationale-record", "name": "Estimate, reserve external reference, authority limit, review and change rationale record", "description": "Versioned evidence-bearing claim-handling record for estimate, reserve external reference, authority limit, review and change rationale.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus estimate-reserve-external-reference-authority-limit-review-and-change-rationale assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason", "name": "Coverage, liability, benefit, item adjudication, acceptance, partial denial and reason", "description": "Records coverage, liability, benefit, item adjudication, acceptance, partial denial and reason as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ], "questions": [ { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason-q01", "text": "What stable identities, classes, values and explicit unknowns establish coverage, liability, benefit, item adjudication, acceptance, partial denial and reason?", "kind": "decision", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support coverage, liability, benefit, item adjudication, acceptance, partial denial and reason?", "kind": "access", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason-q03", "text": "How may coverage, liability, benefit, item adjudication, acceptance, partial denial and reason be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "decision", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason-data", "name": "Coverage, liability, benefit, item adjudication, acceptance, partial denial and reason data", "description": "Structured data for coverage, liability, benefit, item adjudication, acceptance, partial denial and reason with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ] } ], "artifacts": [ { "id": "coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason-record", "name": "Coverage, liability, benefit, item adjudication, acceptance, partial denial and reason record", "description": "Versioned evidence-bearing claim-handling record for coverage, liability, benefit, item adjudication, acceptance, partial denial and reason.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus coverage-liability-benefit-item-adjudication-acceptance-partial-denial-and-reason assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "offers-negotiation-settlement-payment-and-recovery-instructions", "name": "Offers, negotiation, settlement, payment and recovery instructions", "description": "Groups claim-handling context for offers, negotiation, settlement, payment and recovery instructions.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ], "findings": [ { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms", "name": "Reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms", "description": "Records reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ], "questions": [ { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms-q01", "text": "What stable identities, classes, values and explicit unknowns establish reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms?", "kind": "lifecycle", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms?", "kind": "exception", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms-q03", "text": "How may reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "temporal", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms-data", "name": "Reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms data", "description": "Structured data for reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ] } ], "artifacts": [ { "id": "reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms-record", "name": "Reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms record", "description": "Versioned evidence-bearing claim-handling record for reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus reasoned-offer-counteroffer-negotiation-acceptance-release-and-settlement-terms assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ] } ], "inline_only_rationale": null }, { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference", "name": "Payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference", "description": "Records payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ], "questions": [ { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference-q01", "text": "What stable identities, classes, values and explicit unknowns establish payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference?", "kind": "relationship", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference?", "kind": "identity", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference-q03", "text": "How may payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "composition", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference-data", "name": "Payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference data", "description": "Structured data for payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ] } ], "artifacts": [ { "id": "payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference-record", "name": "Payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference record", "description": "Versioned evidence-bearing claim-handling record for payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus payment-instruction-payee-allocation-currency-tax-interest-offset-and-clearing-reference assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-011" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "communications-disputes-fraud-and-recoveries", "name": "Communications, disputes, fraud and recoveries", "description": "Groups governed context for communications, disputes, fraud and recoveries.", "rationale": "Status and review paths remain accessible and attributable while complaint, legal, fraud and recovery cases retain independent authority.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-015" ], "layers": [ { "id": "status-communications-deadlines-complaints-and-reviews", "name": "Status communications, deadlines, complaints and reviews", "description": "Groups claim-handling context for status communications, deadlines, complaints and reviews.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ], "findings": [ { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline", "name": "Status update, request, response, reason, language, channel, delivery and deadline", "description": "Records status update, request, response, reason, language, channel, delivery and deadline as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ], "questions": [ { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline-q01", "text": "What stable identities, classes, values and explicit unknowns establish status update, request, response, reason, language, channel, delivery and deadline?", "kind": "temporal", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support status update, request, response, reason, language, channel, delivery and deadline?", "kind": "authority", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline-q03", "text": "How may status update, request, response, reason, language, channel, delivery and deadline be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "evidence", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline-data", "name": "Status update, request, response, reason, language, channel, delivery and deadline data", "description": "Structured data for status update, request, response, reason, language, channel, delivery and deadline with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ] } ], "artifacts": [ { "id": "status-update-request-response-reason-language-channel-delivery-and-deadline-record", "name": "Status update, request, response, reason, language, channel, delivery and deadline record", "description": "Versioned evidence-bearing claim-handling record for status update, request, response, reason, language, channel, delivery and deadline.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus status-update-request-response-reason-language-channel-delivery-and-deadline assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ] } ], "inline_only_rationale": null }, { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference", "name": "Internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference", "description": "Records internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ], "questions": [ { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference-q01", "text": "What stable identities, classes, values and explicit unknowns establish internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference?", "kind": "relationship", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference?", "kind": "relationship", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference-q03", "text": "How may internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "interoperability", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference-data", "name": "Internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference data", "description": "Structured data for internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ] } ], "artifacts": [ { "id": "internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference-record", "name": "Internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference record", "description": "Versioned evidence-bearing claim-handling record for internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus internal-review-complaint-ombudsman-arbitration-litigation-appeal-and-remedy-reference assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009" ] } ], "inline_only_rationale": null } ] }, { "id": "fraud-referral-subrogation-salvage-and-third-party-recovery", "name": "Fraud referral, subrogation, salvage and third-party recovery", "description": "Groups claim-handling context for fraud referral, subrogation, salvage and third-party recovery.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ], "findings": [ { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice", "name": "Fraud indicator, referral, authority, restriction, outcome reference and non-prejudice", "description": "Records fraud indicator, referral, authority, restriction, outcome reference and non-prejudice as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ], "questions": [ { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice-q01", "text": "What stable identities, classes, values and explicit unknowns establish fraud indicator, referral, authority, restriction, outcome reference and non-prejudice?", "kind": "security", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support fraud indicator, referral, authority, restriction, outcome reference and non-prejudice?", "kind": "provenance", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice-q03", "text": "How may fraud indicator, referral, authority, restriction, outcome reference and non-prejudice be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "quality", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice-data", "name": "Fraud indicator, referral, authority, restriction, outcome reference and non-prejudice data", "description": "Structured data for fraud indicator, referral, authority, restriction, outcome reference and non-prejudice with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ] } ], "artifacts": [ { "id": "fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice-record", "name": "Fraud indicator, referral, authority, restriction, outcome reference and non-prejudice record", "description": "Versioned evidence-bearing claim-handling record for fraud indicator, referral, authority, restriction, outcome reference and non-prejudice.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus fraud-indicator-referral-authority-restriction-outcome-reference-and-non-prejudice assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference", "name": "Subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference", "description": "Records subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ], "questions": [ { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference-q01", "text": "What stable identities, classes, values and explicit unknowns establish subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference?", "kind": "relationship", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference?", "kind": "process", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference-q03", "text": "How may subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "state", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference-data", "name": "Subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference data", "description": "Structured data for subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ] } ], "artifacts": [ { "id": "subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference-record", "name": "Subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference record", "description": "Versioned evidence-bearing claim-handling record for subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus subrogation-salvage-contribution-reinsurance-recovery-right-handoff-and-proceeds-reference assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "lifecycle-quality-provenance-retention-interoperability-and-agents", "name": "Lifecycle, quality, provenance, retention, interoperability and agents", "description": "Groups governed context for lifecycle, quality, provenance, retention, interoperability and agents.", "rationale": "Append-only state, service observations and safe projections preserve reconstruction, fairness and accountability across systems.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "layers": [ { "id": "lifecycle-events-reopening-quality-and-fairness-observation", "name": "Lifecycle events, reopening, quality and fairness observation", "description": "Groups claim-handling context for lifecycle events, reopening, quality and fairness observation.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ], "findings": [ { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event", "name": "Notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event", "description": "Records notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ], "questions": [ { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event-q01", "text": "What stable identities, classes, values and explicit unknowns establish notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event?", "kind": "event", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event?", "kind": "decision", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event-q03", "text": "How may notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "measurement", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event-data", "name": "Notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event data", "description": "Structured data for notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event-record", "name": "Notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event record", "description": "Versioned evidence-bearing claim-handling record for notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus notified-registered-triaged-investigating-decided-settled-closed-reopened-and-corrected-event assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation", "name": "Timeliness, fairness, consistency, explanation, burden, complaint and outcome observation", "description": "Records timeliness, fairness, consistency, explanation, burden, complaint and outcome observation as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ], "questions": [ { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation-q01", "text": "What stable identities, classes, values and explicit unknowns establish timeliness, fairness, consistency, explanation, burden, complaint and outcome observation?", "kind": "quality", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support timeliness, fairness, consistency, explanation, burden, complaint and outcome observation?", "kind": "temporal", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation-q03", "text": "How may timeliness, fairness, consistency, explanation, burden, complaint and outcome observation be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "lifecycle", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation-data", "name": "Timeliness, fairness, consistency, explanation, burden, complaint and outcome observation data", "description": "Structured data for timeliness, fairness, consistency, explanation, burden, complaint and outcome observation with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation-record", "name": "Timeliness, fairness, consistency, explanation, burden, complaint and outcome observation record", "description": "Versioned evidence-bearing claim-handling record for timeliness, fairness, consistency, explanation, burden, complaint and outcome observation.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus timeliness-fairness-consistency-explanation-burden-complaint-and-outcome-observation assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null } ] }, { "id": "provenance-privacy-retention-projection-and-safe-agent-operations", "name": "Provenance, privacy, retention, projection and safe agent operations", "description": "Groups claim-handling context for provenance, privacy, retention, projection and safe agent operations.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "findings": [ { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference", "name": "Actor, tool, source, method, derivation, event time, knowledge time, access and audit reference", "description": "Records actor, tool, source, method, derivation, event time, knowledge time, access and audit reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference-q01", "text": "What stable identities, classes, values and explicit unknowns establish actor, tool, source, method, derivation, event time, knowledge time, access and audit reference?", "kind": "provenance", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support actor, tool, source, method, derivation, event time, knowledge time, access and audit reference?", "kind": "composition", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference-q03", "text": "How may actor, tool, source, method, derivation, event time, knowledge time, access and audit reference be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "event", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference-data", "name": "Actor, tool, source, method, derivation, event time, knowledge time, access and audit reference data", "description": "Structured data for actor, tool, source, method, derivation, event time, knowledge time, access and audit reference with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference-record", "name": "Actor, tool, source, method, derivation, event time, knowledge time, access and audit reference record", "description": "Versioned evidence-bearing claim-handling record for actor, tool, source, method, derivation, event time, knowledge time, access and audit reference.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus actor-tool-source-method-derivation-event-time-knowledge-time-access-and-audit-reference assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability", "name": "Retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability", "description": "Records retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability-q01", "text": "What stable identities, classes, values and explicit unknowns establish retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability?", "kind": "retention", "answer_data": [ "identities and classifications", "declared values and states", "explicit unknowns" ] }, { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability-q02", "text": "Which authority, source, method, evidence, event time, knowledge time, confidence and limits support retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability?", "kind": "evidence", "answer_data": [ "authority and source", "method and evidence", "times, confidence and limits" ] }, { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability-q03", "text": "How may retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability be validated, challenged, corrected, related, retained or disposed without losing history?", "kind": "retention", "answer_data": [ "validation and challenge", "correction and relationships", "retention and disposition" ] } ], "data_elements": [ { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability-data", "name": "Retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability data", "description": "Structured data for retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability with authority, time, state, evidence and access marking.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability-record", "name": "Retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability record", "description": "Versioned evidence-bearing claim-handling record for retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability.", "media_or_form": [ "logical claim-handling assertion", "request, assessment, decision, instruction, event or evidence record" ], "serial": true, "identity_strategy": "Handling case ID plus retention-hold-redaction-mapping-loss-idempotency-dry-run-post-check-and-contestability assertion or event ID; claim number, title, date, amount and digest never identify the handling case alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null } ] } ] } ] }, "functions": [ { "id": "register-handling-case", "name": "Register handling case", "description": "Governed operation to register handling case with attributable evidence and no hidden master-system mutation.", "inputs": [ "mandate", "claim reference", "profile", "owner" ], "outputs": [ "handling case root" ], "preconditions": [ "identity, duplicate, boundary and authority pass" ], "effects": [ "a bounded handling case exists" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-015" ] }, { "id": "acknowledge-and-triage-notification", "name": "Acknowledge and triage notification", "description": "Governed operation to acknowledge and triage notification with attributable evidence and no hidden master-system mutation.", "inputs": [ "notification", "contact and channel", "policy hints" ], "outputs": [ "acknowledgement and triage assertion" ], "preconditions": [ "received time, accessibility and routing pass" ], "effects": [ "notification is recorded without implying coverage or acceptance" ], "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007" ] }, { "id": "bind-claim-policy-loss-and-parties", "name": "Bind claim, policy, loss and parties", "description": "Governed operation to bind claim, policy, loss and parties with attributable evidence and no hidden master-system mutation.", "inputs": [ "case", "authoritative references", "profile" ], "outputs": [ "source-qualified binding set" ], "preconditions": [ "master identity, role and temporal validity pass" ], "effects": [ "the case resolves its external subjects without copying them" ], "source_refs": [ "SRC-003", "SRC-007", "SRC-010" ] }, { "id": "plan-and-conduct-investigation", "name": "Plan and conduct investigation", "description": "Governed operation to plan and conduct investigation with attributable evidence and no hidden master-system mutation.", "inputs": [ "case", "issues", "evidence needs", "authority" ], "outputs": [ "investigation activities and evidence requests" ], "preconditions": [ "necessity, proportionality, competence and conflict checks pass" ], "effects": [ "open questions and attributable work are visible" ], "source_refs": [ "SRC-001", "SRC-003", "SRC-014", "SRC-015" ] }, { "id": "assess-coverage-liability-and-benefit", "name": "Assess coverage, liability and benefit", "description": "Governed operation to assess coverage, liability and benefit with attributable evidence and no hidden master-system mutation.", "inputs": [ "policy and claim refs", "evidence", "rules", "methods" ], "outputs": [ "reasoned assessment assertions" ], "preconditions": [ "source, uncertainty, authority and item reconciliation pass" ], "effects": [ "coverage, liability, causation and amounts remain separate conclusions" ], "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-010", "SRC-011" ] }, { "id": "refer-suspected-fraud", "name": "Refer suspected fraud", "description": "Governed operation to refer suspected fraud with attributable evidence and no hidden master-system mutation.", "inputs": [ "indicator assertion", "case", "referral rule" ], "outputs": [ "restricted referral and receipt" ], "preconditions": [ "threshold, authority, minimization and non-prejudice pass" ], "effects": [ "a suspicion is escalated without becoming a fraud finding" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-014" ] }, { "id": "issue-reasoned-decision-or-offer", "name": "Issue reasoned decision or offer", "description": "Governed operation to issue reasoned decision or offer with attributable evidence and no hidden master-system mutation.", "inputs": [ "assessments", "authority limit", "applicable duties" ], "outputs": [ "immutable decision, offer or reasoned reply" ], "preconditions": [ "explanation, timing, review and delivery pass" ], "effects": [ "the claimant receives an attributable result without implying payment" ], "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-011" ] }, { "id": "settle-and-initiate-financial-handoffs", "name": "Settle and initiate financial handoffs", "description": "Governed operation to settle and initiate financial handoffs with attributable evidence and no hidden master-system mutation.", "inputs": [ "accepted terms", "payee and allocation refs", "recovery refs" ], "outputs": [ "settlement event and external instructions" ], "preconditions": [ "acceptance, release scope, segregation and post-check pass" ], "effects": [ "payment, reserve and recovery masters receive bounded instructions" ], "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-009" ] }, { "id": "review-dispute-reopen-or-correct", "name": "Review, dispute, reopen or correct", "description": "Governed operation to review, dispute, reopen or correct with attributable evidence and no hidden master-system mutation.", "inputs": [ "case revision", "challenge or new evidence", "authority" ], "outputs": [ "review result and successor case events" ], "preconditions": [ "independence, reason, rights and lineage pass" ], "effects": [ "contested outcomes remain visible and earlier evidence is preserved" ], "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-015" ] }, { "id": "close-project-retain-and-audit", "name": "Close, project, retain and audit", "description": "Governed operation to close, project, retain and audit with attributable evidence and no hidden master-system mutation.", "inputs": [ "case", "closure basis", "target profile", "policy" ], "outputs": [ "closure, projection or disposition event" ], "preconditions": [ "unresolved obligations, mapping loss, hold, privacy and idempotency pass" ], "effects": [ "context remains reconstructable, interoperable and accountable" ], "source_refs": [ "SRC-003", "SRC-004", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "composition": [ { "target": "WM-ECO-036 Insurance Claim", "relation": "COMPOSE", "purpose": "Candidate composition preserving claim identity and handling-case separation; no approved edge exists.", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-010", "SRC-011" ] }, { "target": "WM-ECO-003 Insurance Policy and policy, coverage, loss, party, asset, injury and damage models", "relation": "REFERENCE", "purpose": "Bind authoritative contract and subject facts while their masters retain identity and lifecycle.", "required": true, "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] }, { "target": "Evidence, Expert, Fraud Case, Complaint, Ombudsman, Arbitration, Court Case, Communication, Audit and Record models", "relation": "REFERENCE", "purpose": "Bind investigation evidence, referrals, redress and accountable communication without lifecycle cascade.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-007", "SRC-008", "SRC-015" ] }, { "target": "Reserve, Payment, Accounting Entry, Reinsurance, Subrogation, Salvage and Recovery models", "relation": "REFERENCE", "purpose": "Issue bounded instructions and record receipts while external financial and rights masters own execution and proceeds.", "required": false, "source_refs": [ "SRC-003", "SRC-007", "SRC-011" ] }, { "target": "IAIS ICP, NAIC claim-conduct models, FCA ICOBS, EU motor and distribution directives, HL7 FHIR and ACORD P&C", "relation": "ALIGN", "purpose": "Project version-pinned conduct, regulatory and exchange views with declared jurisdiction, maturity and information loss.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-013" ] } ], "serviceLayers": { "dimension": { "owner_package_requirements": [ "Dimension owner and insurance-claim-handling mandate", "Claim, policy, coverage, loss, party, evidence, fraud, complaint, legal, payment, reserve, communication, audit and record registries", "Master mappings for claims, policies, parties, losses, assets, injuries, evidence, experts, payments and recoveries", "Claims conduct, authority, privacy, security, complaints, retention and agent policies" ], "namespace_guidance": "Mint handling-case, notification, assignment, request, assessment, decision, offer, settlement, handoff, communication, review, closure and event IDs; preserve every external master identifier.", "registry_links": [ "https://ver.cy/models/", "https://ver.cy/model-agent-protocol.md" ] }, "canon_and_patch": { "canonicalization_rules": [ "Canonicalize by authoritative master-system handling-case identifier, claim binding, insurer profile and lineage head, never claimant name, claim number alone, date or amount.", "Keep notification, completeness, coverage, liability, estimate, reserve, decision, offer, settlement, instruction, execution and observation distinct." ], "patch_rules": [ "Extensions declare insurance line, jurisdiction, authority, privacy, lifecycle, deadline and interoperability effects.", "Released assessments, decisions, offers, settlements and evidence-use records are immutable; corrections and reopening create successors.", "Never silently change claim or policy binding, evidence relied upon, decision reason, amount, authority, deadline, access or retention." ], "compatibility_rules": [ "Ignore additive fields only when identity, boundary, authority, claim binding, lifecycle, evidence, reason and provenance survive.", "Standards and regulatory projections pin versions, scope and jurisdiction and declare information loss." ] }, "artifact_rules": { "identity_priority": [ "Authoritative master-system handling-case identifier qualified by insurer, source and profile.", "Governed globally resolvable handling-case IRI.", "Dimension UUID when neither preceding identifier exists." ], "timestamp_rule": "Use RFC 3339 timestamps with seconds and explicit offset or Z; separate loss, notification, receipt, acknowledgement, request, response, assessment, decision, offer, acceptance, instruction, execution, observation, closure, ingestion and knowledge times.", "serial_naming_rule": "Use {handling-case-id}--{decision-review-or-event-id}--{artifact-kind}--{assertion-id}.", "integrity_rule": "Store digest, media type, case and claim binding, source versions, actor, event and knowledge times, access marking and provenance." }, "policies": [ "The handling case is not an Insurance Claim, Insurance Policy, Loss Event, Person, Organization, Role, Asset, Damage, Injury, Evidence, Expert, Fraud Case, Complaint, Legal Case, Payment, Reserve, Communication, Audit or Record master.", "Notification, completeness, admissibility, coverage, liability, benefit, reserve, decision, offer, settlement, payment and closure remain separate.", "Handling ownership never transfers or cascades ownership of referenced masters.", "Agents cannot accept or deny coverage, accuse fraud, settle, pay, waive rights, disclose protected data or dispose records without delegated authority." ], "crud": { "read": [ "Resolve access purpose, case profile, policies, authoritative claim and policy bindings, work, evidence use, assessments, decisions, communications, disputes, handoffs, exceptions and holds." ], "create": [ "Bind stable handling-case identity, boundary, owner, mandate, profile and authoritative claim and policy references before assessment." ], "update": [ "Append successor assignments, requests, assessments, decisions, offers, reviews, handoffs and events with authority, reason, event time, knowledge time and expected revision." ], "delete": [ "Apply insurance, privacy, legal-hold and records retention policy; retire or tombstone the handling case separately and never cascade deletion to external masters." ] }, "roles": [ { "name": "Claim handling owner", "responsibilities": [ "Own case scope, mandate, service and lifecycle." ] }, { "name": "Claim handler or adjuster", "responsibilities": [ "Own assigned intake, investigation, assessment and communications within authority." ] }, { "name": "Coverage and legal reviewer", "responsibilities": [ "Own policy interpretation and reasoned exception review." ] }, { "name": "Medical, engineering or valuation expert", "responsibilities": [ "Own source-qualified expert observations without deciding the claim outside delegation." ] }, { "name": "Settlement authority", "responsibilities": [ "Own decision and settlement approvals within recorded limits." ] }, { "name": "Fraud referral steward", "responsibilities": [ "Own restricted indicator review and independent referral." ] }, { "name": "Complaint and dispute reviewer", "responsibilities": [ "Own impartial review, escalation and redress handoffs." ] }, { "name": "Privacy, records and assurance steward", "responsibilities": [ "Own protected views, holds, retention, disclosure and auditability." ] } ], "access": { "default_rule": "Deny personal, health, financial, location, fraud-indicator, legal-advice, reserve and settlement-strategy data unless a purpose-bound policy permits the minimum necessary view.", "scopes": [ "bundle", "layer", "finding", "artifact" ], "exceptions": [ "Declared claimant, representative, regulator, auditor, court, ombudsman, emergency, reinsurer or recovery-party access must cite authority, be scoped, time-limited where applicable and logged." ], "audit_requirements": [ "Log actor, agent, role, purpose, handling case, operation, authority, policy, RFC 3339 time, affected fields, source revision and outcome without unnecessary protected content." ] }, "agents_bootstrap": { "filename": "AGENTS.md", "required_fields": [ "Name", "Type", "Specification URL", "Storage type URL", "Interface URL", "Processes URL" ], "read_order": [ "Read Dimension insurance, claims conduct, policy, privacy, security, complaint, records and agent policies.", "Read this model and linked claim, policy, party, loss, evidence, payment, fraud, complaint, dispute, communication and audit models before mutation." ] } }, "coverage": { "claim": "WM-ACT-045 covers one governed insurance-claim-handling case from notification and triage through investigation, reasoned decision, settlement handoffs, review, closure and retention. It separates handling-case work and decisions from independent claim, policy, loss, party, evidence, fraud, complaint, legal, payment, reserve, communication and audit masters. Line-of-business profiles, jurisdictional rules, an approved WM-ECO-036 edge, full ACORD or FHIR conformance and independent external review remain deferred.", "confidence": "medium", "checklist": [ { "dimension": "identity", "status": "covered", "notes": "Identity is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "classification and definition", "status": "covered", "notes": "Classification and definition is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "direct properties", "status": "gap", "notes": "Direct properties is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "recognition and observation", "status": "covered", "notes": "Recognition and observation is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "capabilities and possible actions", "status": "covered", "notes": "Capabilities and possible actions is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "composition", "status": "covered", "notes": "Composition is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "lifecycle", "status": "covered", "notes": "Lifecycle is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "relationships", "status": "covered", "notes": "Relationships is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "temporal", "status": "covered", "notes": "Temporal is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "spatial", "status": "gap", "notes": "Spatial is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "provenance", "status": "covered", "notes": "Provenance is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "ownership and stewardship", "status": "covered", "notes": "Ownership and stewardship is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "validation and quality", "status": "covered", "notes": "Validation and quality is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "access and privacy", "status": "covered", "notes": "Access and privacy is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "retention and deletion", "status": "covered", "notes": "Retention and deletion is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "interoperability", "status": "covered", "notes": "Interoperability is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." } ], "known_omissions": [ "Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.", "WM-ECO-036 COMPOSE WM-ACT-045 is a candidate relation, not an approved edge.", "Life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance and catastrophe handling require separate profiles.", "ACORD evidence is limited to public overview material and HL7 FHIR R5 financial resources are Trial Use; no full ACORD or universal FHIR conformance is claimed." ], "conflicts": [ "Notification, valid claim, coverage, liability, benefit, decision, offer, settlement and payment are not interchangeable.", "Fraud suspicion can justify controlled investigation or referral but is not a fraud determination and must not silently prejudice ordinary handling.", "Prompt settlement, thorough investigation, privacy, evidence preservation, claimant accessibility and anti-fraud controls can conflict and require source-qualified proportionality decisions." ], "regional_assumptions": [ "Deadlines, reasonableness, settlement duties, disclosure, interest, limitation and appeal rights depend on jurisdiction and policy class.", "NAIC models are United States model texts rather than automatically applicable state law; FCA and EU sources are regional profiles.", "Health claim exchanges and patient-facing projections vary by trading-partner agreement, jurisdiction and FHIR implementation guide." ], "adversarial_checks": [ "Reject a case without stable identity, claim binding, insurer or responsible authority, profile and lineage head.", "Reject policy existence represented as coverage, investigation represented as proof, reserve represented as offer, decision represented as payment or closure represented as extinguished rights.", "Reject a fraud label based only on an indicator or automated score, and reject adverse action without attributable authority and review path.", "Reject corrections that overwrite assessments, evidence use, decisions, offers, settlements, communications or review history.", "Reject autonomous denial, settlement, payment, rights waiver, protected disclosure or disposal outside delegated authority." ] }, "researchAdjudication": { "providerMode": "single-provider-waiver", "activeProviders": [ "codex" ], "waivedProviders": [ "claude", "grok" ], "providerPolicy": { "contract_version": "1.0.0", "mode": "single-provider-waiver", "effective_at": "2026-09-06T00:00:00Z", "scope": "Canonical single-stream subject-model research after the six-workstream consolidation", "active_providers": [ "codex" ], "waived_providers": [ { "provider": "claude", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "Claude produced no result on prior 1800-second and 900-second attempts and again timed out on bounded 600-second Sonnet and 300-second Haiku passes. The owner prioritized completion over provider availability." }, { "provider": "grok", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "The repository owner authorized completion without Grok when Grok is unavailable, slow or schema-invalid. Grok may still be attempted as a bounded supplemental reviewer, but its failure never blocks a valid Claude plus no-tools result." } ], "review_rule": "Codex may complete source-grounded fallback research after bounded Claude and Grok attempts fail. It requires a separate no-tools adversarial audit and remains reviewable-draft with a visible absence-of-external-review hold.", "supplemental_provider_attempts": [ { "provider": "claude", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." }, { "provider": "grok", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." } ] }, "boundaryDecision": { "entry_kind": "aggregate", "status": "accepted", "rationale": "The subject-model entry kind aggregate is sound because one handling case coordinates intake, work, assessments, decisions, communications and handoffs without absorbing external masters. The frozen registry value standalone-mm classifies the record plane and does not conflict with the subject-model kind." }, "decisions": [ { "concept": "Handling case versus Insurance Claim master", "disposition": "accepted", "rationale": "The Insurance Claim master owns claim identity and substantive policy-loss-demand assertions. WM-ACT-045 owns one processing case, its assignments, evidence use, assessments, decisions, communications and handoffs. Five boundary notes and non-cascade policies preserve that division." }, { "concept": "Notification, coverage, decision, settlement and payment separation", "disposition": "accepted", "rationale": "Separate findings and functions distinguish receipt, completeness, policy binding, coverage and liability assessment, reasoned result, offer, acceptance, external payment instruction and observed execution. The model explicitly rejects shortcuts among these states." }, { "concept": "Fraud indicator and referral boundary", "disposition": "accepted", "rationale": "A source-qualified indicator may start a restricted referral but cannot become a fraud finding or silently prejudice ordinary handling. Adverse action requires attributable authority and a review path; an external Fraud Case owns the investigation outcome." }, { "concept": "WM-ECO-036 candidate composition", "disposition": "deferred", "rationale": "The registry ledger proposes WM-ECO-036 COMPOSE WM-ACT-045 for claim-versus-process separation. It remains candidate metadata, not an approved edge. The standalone handling specification is coherent through a required external claim reference, so this limits relationship-completeness claims but does not block reviewable-draft publication." }, { "concept": "Immutable records and successor corrections", "disposition": "accepted", "rationale": "Released assessments, evidence-use records, decisions, offers and settlements are immutable. Reopening or correction creates a separately identified successor with reason, authority, event and knowledge times, preventing audit history from being overwritten." }, { "concept": "Privacy and confidential access", "disposition": "accepted-with-profile-hold", "rationale": "Default-deny access covers personal, health, financial, location, fraud, legal, reserve and settlement-strategy data. Purpose-bound exceptions require authority, scope and logging. Concrete role bindings, redaction and jurisdictional rights must be supplied by the adopting Dimension profile." }, { "concept": "Regulatory and exchange source scope", "disposition": "accepted", "rationale": "IAIS supplies the neutral conduct baseline. NAIC, FCA, EIOPA, EU and UK sources are explicit regional profiles. FHIR R5 financial resources are Trial Use and ACORD evidence is public overview only; neither supports a universal or full conformance claim." }, { "concept": "Single-provider waiver", "disposition": "accepted-with-mandatory-hold", "rationale": "One Claude Sonnet and one Grok 4.6 attempt for WM-ACT-045 each timed out after 120 seconds. Owner-approved policy permits source-grounded Codex fallback after this separate no-tools audit. Confidence remains medium and assurance remains reviewable-draft with a visible absence-of-external-review hold." } ], "publicationHolds": [ "Absence-of-external-review hold: one Claude Sonnet and one Grok 4.6 attempt for WM-ACT-045 each timed out after 120 seconds. No external result was admitted; the model remains a reviewable draft after the separate no-tools audit.", "Registry edge approval hold: WM-ECO-036 COMPOSE WM-ACT-045 remains candidate metadata. This blocks complete relationship claims, not standalone reviewable-draft publication.", "Jurisdiction-profile hold: deadlines, reasonableness, disclosures, interest, limitation, appeals, settlement and record retention must bind applicable law and policy class before operational use.", "Insurance-line profile hold: life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance and catastrophe handling need specialized requirements.", "Interoperability hold: FHIR R5 financial resources are Trial Use and ACORD P&C evidence is limited to public overview material; projections require version-pinned mappings and loss declarations.", "Independent external review was explicitly waived by the repository owner; this codex-only result remains a reviewable draft." ], "deferredResearch": [ "Approve or reject the WM-ECO-036 composition and define claim-to-handling-case cardinality, reopening and multi-insurer coordination semantics.", "Create line-of-business profiles with specialized evidence, benefit, authority, reserve, settlement and recovery rules.", "Create jurisdiction profiles for deadlines, reasoned decisions, interest, limitation, privacy, complaints, redress, retention and catastrophe duties.", "Test full licensed ACORD mappings and selected FHIR implementation guides without treating either as universal semantics.", "Obtain supplemental Claude or Grok review and resolve any material challenge before canonical promotion." ] }, "statistics": { "sources": 16, "bundles": 6, "layers": 12, "findings": 24, "questions": 72, "artifacts": 24, "functions": 10 } }